Brief Communication

Childhood Headache Attributed to Airplane Travel: A Case Report

Journal of Child Neurology 1-3 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0883073814539555 jcn.sagepub.com

Kirsty Rogers, MBBS, BSc1, Nadia Rafiq, MRCPCH1, Prab Prabhakar, FRCPCH2, and Mas Ahmed, MRCP, FRCPCH1

Abstract Headache attributed to airplane flights is a rare form of headache disorder. This case study describes an 11-year-old girl with recurrent, severe, frontal headaches occurring during airplane travel. The episodes were associated with dizziness and facial pallor but no additional symptoms and showed spontaneous resolution on landing. Blood tests and imaging revealed no abnormalities. The present case fulfils the criteria for airplane headache recently included in the revised edition of the International Classification of Headache Disorders (ICHD-III Beta). Only a few cases of airplane headache have been reported in children. To our knowledge, this is the fourth case. We review the current literature on this rare syndrome and discuss various proposed pathophysiological mechanisms. Keywords airplane headache, pediatric, childhood headache disorders, case report Received October 04, 2013. Accepted for publication May 15, 2014.

Background Airplane headache is a relatively rare form of headache disorder. A recent report identified an increasing number of cases and led to the proposal of diagnostic criteria for this condition.1 Subsequently, it has been formally recognized as a new category of headache and included in the revision of the International Classification of Headache Disorders (ICHD-III Beta version).2 In the literature, airplane headache is reported mainly in adults. A total of 3 cases within the pediatric age group have been published to date.3 Here we present a further pediatric case.

Case History This is an 11-year-old neurologically normal girl with a history of episodic migraine referred to our headache clinic with sharp, throbbing, stabbing, severe, unilateral frontal headaches that exclusively occurred during airplane travel. Each headache lasted for less than half an hour and was associated with dizziness and facial pallor. She denied any associated photophobia, phonophobia, nausea, vomiting, olfactory disturbances, autonomic features, or any form of aura. There was no history of preceding viral infection, trauma, fever, lethargy, or clinical evidence of sinusitis. Consciousness was maintained throughout the attacks and there were no prodromal or postictal phases. A more detailed history revealed that she had experienced her first headache while on a long haul transatlantic flight. The

headache was triggered when the airplane took off; it diminished in intensity during the flight and reemerged as the plane began to descend. Her symptoms disappeared shortly after landing. On a separate occasion, she suffered a similar attack during airplane descent only. While travelling to Turkey, she experienced a sharp intense headache lasting 10 to 15 minutes with associated dizziness and pallor that completely and spontaneously subsided on arrival in the airport. In total, she had embarked on 3 airplane flights over the last year and her symptoms had manifested on every occasion. She additionally reported a similar headache attack triggered by a roller coaster ride. Her past medical history was significant for adenotonsillectomy only. She does not take any regular medications and has no known allergies. Her birth history was unremarkable. She was up-to-date with her vaccinations and showed good academic progress at school. The family history showed migraine-type headache in multiple family members on the maternal side.

1

Department of Pediatrics, Queen’s University Hospital, Romford, United Kingdom 2 Department of Pediatric Neurology, Great Ormond Street Hospital, London, United Kingdom Corresponding Author: Kirsty Rogers, MBBS, BSc, Pediatric Department, Queen’s Hospital, Rom Valley Way, Romford, Essex, RM7 0AG, United Kingdom. Email: [email protected]

Downloaded from jcn.sagepub.com at UNIV OF MICHIGAN on February 28, 2015

2

Journal of Child Neurology

A

At least 2 episodes of headache fulfilling criterion C

B

The patient is travelling by airplane

C

Evidence of causation demonstrated by at least 2 of the following: 1. Headache has developed exclusively during airplane travel 2. Either or both of the following: a) headache has worsened in temporal relation to ascent after take-off and/or descent prior to landing of the aeroplane b) headache has spontaneously improved within 30 minutes after the ascent or descent of the airplane is completed 3. Headache is severe, with at least 2 of the following 3 characteristics: a) unilateral location b) orbitofrontal location (parietal spread may occur) c) jabbing or stabbing quality (pulsation may also occur)

D

Not better accounted for by another ICHD-III diagnosis

Figure 1. International classification of headache disorders (ICHD-III Beta) diagnostic criteria.

General, neurologic, and ophthalmologic examinations were unremarkable. Her weight and height were age appropriate and blood pressure was normal. Specialist ear, nose, throat review did not identify any underlying inner ear pathology or other ear, nose, throat–related cause. Basic biochemical and hematologic tests and brain magnetic resonance imaging (MRI) revealed no abnormalities. Awake electroencephalographic (EEG) recording showed normal background but intermittent bursts of generalized slow activity. Such abnormality was not associated with headaches or other clinical events.

Discussion Airplane headache is a rare form of headache disorder associated only with airplane travel. The first case of airplane headache was reported in 20043 and there have been a steadily increasing number of reported cases in the following years. In a recent article in Cephalalgia, Italian researchers collected profiles on 75 patients with symptoms suggestive of airplane headache and proposed a set of diagnostic criteria for this condition.1 Following the 2013 International Headache Congress (IHC), headache associated with airplane travel has received formal recognition and been included in the group of secondary headache disorders in the recent update of the International Headache Society classification.2 The recently published ICHD-III criteria are summarized in Figure 1. The pain is typically reported as severe, and may be described as jabbing, stabbing, or pulsatile in quality. It is usually unilateral and localized to fronto-orbital and frontoparietal regions. The

headache is short-lived, with a duration of less than 30 minutes, and occurs exclusively in relation to airplane travel (most frequently during airplane descent). Accompanying symptoms are usually absent and there is spontaneous resolution on landing. Analysis has additionally identified a male preponderance. Most importantly, a diagnosis should only be made once other secondary causes have been ruled out, in particular acute and chronic sinusitis. Headaches in our patient exclusively occurred during airplane travel and fulfill the diagnostic criteria of airplane headache.2 Both physical and biochemical investigations were unremarkable and imaging was free of abnormalities. Her background of episodic migraine is clearly distinct from the head pain experienced during flights in terms of intensity and duration. Interestingly, coexistence of a primary headache disorder is also described in many of the airplane headache patients reported in the literature. The most common associations were found to be tension-type headaches and migraine without aura.3 Despite various proposed mechanisms, the pathophysiology of airplane-related headache remains unclear. A common view is that barotrauma plays a major role.1,3-5 Pressure changes within sinus cavities are thought to affect the ethmoidal nerves, thereby triggering the trigeminovascular system and leading to headache in susceptible individuals. Any factor that results in sensitization of trigeminal nerve endings in nasal and paranasal mucosa may result in similar maladaptation to flight-induced pressure changes and consequently headache attacks. Various proposed hypotheses include anatomic factors, environmental factors (cabin pressure/altitude), and factors reducing sinus ventilation (eg, mucosal edema). Any association with nonorganic/psychiatric factors has yet to be investigated.4 Similar headaches are known to commonly occur on descent from high altitudes or during scuba diving.1,5 A barotrauma-like mechanism is well described in such scenarios. The coexistence of headaches showing similar clinical features but triggered by different situations strengthens the hypothesis of a common pathophysiological mechanism. This case is unusual in that only a few cases of airplane headache have been reported in children. To our knowledge, this is the fourth case in children and adolescents. In 2011, a group of Turkish researchers described 3 cases in the pediatric age group with clinical manifestations suggestive of airplane headache. The patients were aged between 12 and 14. Barotraumas due to nasal mucosal inflammation, adenoidal and tonsillar hypertrophy, and sinusitis were the pathophysiological mechanisms found responsible in these cases.6 Treatment strategies for airplane headache are controversial. Simple analgesics, nonsteroidal anti-inflammatory drugs, and nasal decongestants have all been shown to be helpful prophylactic measures.1,6 Alternatively, a single study suggests the use of triptans as a safe treatment choice for airplane headache.7 The Turkish researchers demonstrated a complete response to singledose triptan treatment in 5 patients. However, given the benign nature of the condition, the use of prophylactic antimigraine medication is not currently recommended, although it may be

Downloaded from jcn.sagepub.com at UNIV OF MICHIGAN on February 28, 2015

Rogers et al

3

useful in severe treatment-resistant cases. Indeed, in the case presented here, reassurance following diagnosis was sufficient and no further management was required.

Declaration of Conflicting Interests The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

Conclusion Whether ‘‘airplane’’ headache is a distinct condition was previously debated. However, following the emergence of an increasing number of case studies, it has undergone formal validation and is now included in the recently published ICHD-III beta edition.2 Field testing is currently underway and publication of the final version is due to take place in the next few years. Although acknowledging the difficulty in translating case reports into evidence-based practice, we are confident that this unique case provides further evidence to support the inclusion of this new category of headache in the International Headache Society Classification. Given the ever-increasing use of airplane travel, awareness of this unique condition can only benefit patient care. Formal recognition of airplane headache as a distinct disorder may favor further in-depth research, improving our knowledge and understanding of a condition that is likely to be more prevalent than currently realized. Author Contributions KR performed the literature review and was the major contributor in writing the manuscript. NR reviewed and revised the draft manuscript. PP and MA were actively involved in the clinical care of the patient and were responsible for acquisition of the clinical data for the study. PP and MA additionally supervised the project and critically reviewed the manuscript. All authors had complete access to the study data and have read and approved the final manuscript as submitted.

The authors received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval Written informed consent was obtained from the patient’s guardian for publication of this case report.

References 1. Mainardi F, Maggioni F, Lisotto C, Zanchin G. Diagnosis and management of headache attributed to airplane travel. Curr Neurol Neurosci Rep. 2013;13:355. 2. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629-808. 3. Atkinson V, Lee L. An unusual case of airplane headache. Headache. 2004;44:438-439. 4. Berilgen MS, Mungen B. Headache associated with airplane travel: report of six cases. Cephalalgia. 2006;26:707-711. 5. Kararizou E, Anagnoustou E, Paraskevas G, et al. Headache during airplane travel (‘‘airplane headache’’): first case in Greece. J Headache Pain. 2011;12:489-491. 6. Ipekdal H, Karadas O, Erdem G, et al. Airplane headache in pediatric age group: report of three cases. J Headache Pain. 2010;11: 533-534. 7. Ipekdal H, Karadas O, Oz O, Ulas U. Can triptans safely be used for airplane headache? Neurol Sci. 2011;32:1165-1169.

Downloaded from jcn.sagepub.com at UNIV OF MICHIGAN on February 28, 2015

Childhood headache attributed to airplane travel: a case report.

Headache attributed to airplane flights is a rare form of headache disorder. This case study describes an 11-year-old girl with recurrent, severe, fro...
80KB Sizes 2 Downloads 3 Views